The hidden cost of failing sight

If the UK Vision Strategy is to become not just another document, but a framework for real action, ministers across the UK will need to dramatically increase their efforts. "The four governments have let us down," RNIB director of policy and advocacy, Fazilet Hadi, says bluntly.

"There has been no real understanding that sight is a public health issue," she says. "We are realists and we know that smoking, obesity and heart disease are up at the top of the public health agenda, but smoking, for example, has an impact on sight loss. They fail to link sight into that broader agenda and they do virtually nothing on sight itself." Ouch.

And it is not just awareness of eye health that needs a lift, but access to treatments, she says. Access to treatment, particularly for conditions such as age-related macular degeneration (AMD) has been a source of huge controversy, hitting the headlines early last year when former MP Alice Mahon revealed that her local primary care trust (PCT) had refused NHS treatment for her recently diagnosed AMD. Mahon's sight deteriorated sharply while she was appealing against the decision, a fate suffered by others denied treatment by cash-strapped PCTs.

Hadi is, of course, concerned that no one should lose their sight unnecessarily, but she adds: "If people get medical interventions early enough, the state can save lots of money." This is because the cost of treatment is far less than the cost of providing support for someone who has become blind.

At the NHS Confederation, David Stout, director of the PCT network, says PCTs are "left with a dilemma". Funding one type of treatment means there is less money for other NHS care, such as for mental illness.

"We're always having to make value judgements about certain alternatives," he says. People are concerned about the so-called "postcode lottery of care", says Stout, but he thinks "it is right" for local PCTs to make different decisions based on local needs.

He says PCTs are also influenced by the evidence for the effectiveness of different treatments, and has to take into account guidance produced by the National Institute for Health and Clinical Excellence (Nice), the body charged with assessing the effectiveness and cost-effectiveness of drugs such as Lucentis, which is used to treat AMD.

Nice guidance

Hadi says there has been "a real battle with Nice." Until December last year, draft Nice guidance recommended Lucentis, but only in cases where the patient had already lost sight in one eye. A public outcry led to a flood of responses to consultation on the draft, and Nice is now expected to amend its advice to allow treatments for the first affected eye.

"Nice says it looks at the costs, but ignores some key areas such as informal care and lost productivity," she says. "When NHS treatment saves someone's sight there are knock-on benefits all the way down the line: fewer falls or accidents, reduced social care support, fewer people leave paid employment and lower expenditure on disability benefits. At every stage, if you take the right measures, you save costs," Hadi continues.

At Nice, a spokesperson agrees that the organisation does not take wider societal costs into account in its assessments, a point also made in December by MPs on the Commons health committee. But he adds: "We're not allowed, we're not able to. The statutory instrument governing Nice only tasks us to look at costs in the NHS." A legal change would be needed to extend the organisation's remit, he says.

Hadi argues: "We don't think the government is going to shower us with extra money, but I think we can use the money there is much more effectively. Let's start by looking at the resources spent now by health and social care and make them work harder and join them up."

Like ophthalmologist Andy Cassels-Brown (see box below), Hadi is aware that primary and secondary care services can end up fighting each other for eye care resources, "but we need to use the money whichever way is best," she continues.

It is important to "break down the boundaries" between optometrists (the high street opticians) and ophthalmologists (medical eye specialists). If some optometrists could get specialist training, they could work with the health service to offer more eye care in the community, she says. But she adds: "I get the feeling that in health settings people feel that more flexible forms [of service] mean less money for them."

Finding a way to pay

Bob Hughes, chief executive of the Association of Optometrists, would also like to see changes in the way funding for eye care works. For optometrists, he says, "there is generally no PCT funding outside the standard eye test, no way of paying optometrists" to do extra work that could forestall the need for hospital treatment.

In this, the Scottish and, in particular Welsh, governments have differed from England, he says. Policy in Wales is now to pay high street optometrists £40 for miscellaneous short procedures. "In Wales and Scotland they have looked at it, trying to take some of the pressure off secondary care. The Westminster government has recognised that but they are relying on PCTs to make the arrangements," Hughes says.

Social services departments are also struggling with funding constraints, particularly after a local government spending settlement described by the Local Government Association as the harshest in a decade. As a result, budgets for the care of elderly people are tighter than ever, and this has a huge impact on support for blind and partially sighted people because most are over 60.

There are around 25,000 children and young people with sight loss, and another 80,000 of working age. But the figure is almost 300,000 among over 60s. The number of people who are registered blind or partially sighted ("very conservative figures," Hadi says) is rising by 36,000 a year in an increasingly ageing population.

Anne Bristow, who is the policy lead for sensory impairment at the Association of Directors of Adult Social Services, says: "It has now been recognised by the government that there is huge pressure on social care budgets," and a green paper on future funding is expected later this year. She adds: "There is not enough money in the longer-term and before the next comprehensive spending review in 2011, this needs to be addressed if we are going to continue to provide the sort of interventions that mean people can have a good life."

But Bristow says that many measures that can improve life for people with sight loss have little to do with either health or social care, such as improved lighting in public places, voice announcements on transport systems, and more open attitudes among employers to potential recruits who are blind or partially sighted.

Such measures require political will and a shift in social attitudes, the other key area that the UK Vision Strategy aims to tackle, to ensure that blind and partially sighted people are able to play a full role in society.

The Department of Health declined to comment on the strategy ahead of its official publication. But its launch should give eye health issues a higher public - and political - profile.

Case study: Andy Cassels-Brown, ophthalmologist

Andy Cassels-Brown is an ophthalmologist at Leeds Teaching Hospitals Trust, where he carries out cataract surgery and treatments for glaucoma, AMD and other eye conditions. He also has a -special interest in community eye health and developing a public health approach to visual impairment.

But there is a hard road ahead. "Eye care and visual impairment has been very low on the government agenda," he says, comparing it with dentistry, where public health messages have been emphasised for decades. He hopes the UK Vision Strategy will help tackle the "under-appreciation of the socio-economic impact of vision loss".

"What the government needs to do is prioritise the detection of people with visual impairment," he urges. Health promotion work and pushing eye-testing into the community, are crucial. Cassels-Brown says vision testing must also be put back into the quality and outcome framework linked to GP contracts, "to raise the profile with GPs".

He also wants to see the integration of eye services into the mainstream health and social care system to ensure they are properly resourced and available to all, including those put off by the potential cost of eye tests and spectacles.

At the moment, (high street) optometrists are not integrated with the NHS, they are all independent practitioners. And the government's £19.32 for doing a sight test doesn't even cover their overheads.

"But the government has relied on the low-cost eye tests as the formal primary eye care service. We need to look at the possibility of having NHS optometrists, particularly in areas of deprivation."

Cassels-Brown cites the Chapeltown area of Leeds where "there is no optometrist but the risk of impairment is higher" as ethnic minority communities are particularly vulnerable to glaucoma or diabetic retinopathy.

But it is important to avoid "tensions" over funding between primary and secondary care, despite the importance of providing more services in the community. He adds: "With an ageing population, they mustn't throw the secondary care baby out with the bathwater."